The Changing State of Public Health

by Christopher Yopp, MPH

This month, a few lamp-posts in downtown London have been padded in order to prevent people from running into them and physically injuring themselves. This has become a large problem recently because of the increase in text messaging via cellular phone while walking. This “Safe Text” street, also known on most maps as Brick Lane, is now a little bit safer for those who cannot be bothered to look up while walking. Some may say natural selection should be allowed to run its course, while others, mainly those who have run into these poles, commend public health officials on their foresight and genius.

Perhaps this kind of public safety intervention is what is called to mind when one hears mention of the field of Public Health. Maybe some people instead associate the concept with visions of an irate Ralph Nader ranting about seatbelts.

In any case, Public Health is an attempt to improve the well-being of a community by studying and managing the risks that affect it. Public health officials try to prevent, rather than have to treat, diseases through surveillance of threats and the promotion of healthy behaviors. The World Health Organization defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Thus, a public health official’s ultimate goal is to create and sustain an environment where everyone is able to be healthy.

The anti-smoking campaign of recent years is an ideal example of this goal; decreasing environmental tobacco smoke has led to a decrease not only in lung-related diseases in not only ex-smokers, but in non-smokers as well. Overall, this campaign has been seen as an effective public health intervention.

However, critics of Public Health, both at the professional and amateur levels, have a different opinion. One critic, a good friend of mine, describes Public Health as “a bunch of obnoxious nonsense, where people are always telling me what I can and cannot do. One week I should eat truckloads of broccoli to prevent getting cancer, and the next, [eating] broccoli is a small step below bathing in plutonium.” Although not very eloquent, my friend does have a point as far as layperson perspective on the proclamations of the discipline.

Public Health, like most every field, always finds itself refining its expressed interpretations of the statistics and trends for what behaviors are “best” for the population. For example, Saturated fats were the worst fats until research identified transfats to be the most deleterious fat, just like the Argentinian Eoraptor was the “oldest dinosaur” before Madagascar’s Prosauropods were dug up. One doesn’t dismiss Paleontology as “pseudoscience” just because new discoveries are made and our understanding of the world concomitantly gets a little update. Where these fields differ, however, is that Public Health news releases and research bulletins often take on the tone of a commandment, and public health officials become “The Smoking Police”, telling people again and again what they already know: Thou shalt not smoke, lest you die of emphysema!

It is easy to understand how this “father knows best” attitude can creep into the field of Public Health. As an observer , it is disheartening to witness people who know all the risk factors to avoid, and yet, still engage in unhealthy behaviors.

Consider this: well over a third of all deaths in the United States can be attributed to a limited number of largely preventable behaviors and exposures, including smoking, poor diet and physical inactivity, and alcohol consumption. That means one out of three deaths that occur in the United States can be averted. Yes, everyone will eventually die, but who doesn’t want another 20 years? This kind of data, along with the knowledge of what interventions can be put into place to change these figures, evokes a certain amount of passion in people in the public health business. Everyone deserves to live a long, healthy life. Personally, I plan to live out my last few days in an Old Folks Home, and I could certainly use some company; from what I understand, it can get fairly lonely.

Unfortunately, this passion often stirs up a certain amount of self-righteousness and, dare I say, arrogance. It is part of a Public Health official’s required background to know what is best to maintain the health of the public (and be able to be continuously updating that knowledge) and, obviously, the public should take heed of their best interests. Regrettably, many public health initiatives do not take the opinions of their target population into account. How often do public health officials consult you about your health concerns or inquire how a given health problem in the community should be addressed? More often than not, a simple public health advisory, outlining the risk factors for a particular disease, is issued and that is all. Public Health officials, as your advocates for better health, sometimes have a difficult time listening to your concerns and what you believe are the most pressing issues.

This is particularly evident in cases within the developing world. Many doctors and public health officials have taken a “Field of Dreams” approach to public health in developing nations. That is, “if we provide it, then they will use it.” Back in the 1960’s to the early 80’s, the Food and Agricultural Organization recognized that years of famine and drought in Uganda had resulted in an impoverished populace. Being good intentioned global citizens, Public Health officials decided to follow a precept attributed to everyone from Native Americans to Africans, “Give a man a fish, and he will eat for a day, but teach him how to fish and he will eat all his life.” The officials believed the best way to address the problem of malnutrition in Uganda was to give Ugandan farmers the equipment that would improve their ability to farm for themselves and reach sustainability.

Millions of dollars were spent shipping brand new tractors for the Ugandans to use on their farms. These tractors were allocated to the best farms in hopes that they, the hardest working farmers, would best take advantage of this technology. This was a grand gesture, but unfortunately short sighted. The public health officials forgot one of the fundamental parts of that phrase. They forgot to properly teach the farmers how to use the tractors and the equally important how to fix them when they broke down. Furthermore the parts necessary for fixing and the gas and oil required for operation of the tractors were not provided. On top of that, the cultural differences with respect to attitudes toward technology were not taken into account, as many of the farmers were reluctant to leave the old ways behind and refused to touch the tractors that had been delivered to their fields. As a result, the tractors rusted in the fields, and farmers went back to using oxen and hoes.

That is not to say that this type of intervention isn’t necessary and useful. Indeed this top down approach can be very effective in the case of national emergencies. Imagine a large natural disaster in the Deep South that destroys infrastructure and leads to great need. Fresh water, food, and housing will have to be provided to a large population. You would want a well-coordinated organization to come in who can successfully manage and direct the humanitarian effort in a timely and effective way. And you would want to make sure that organization is not just FEMA. However, when you want to develop a long-lasting program that will effect change for years to come, you must work hand-in-hand with the target community.

Public health is shifting, and officials are learning from past mistakes. Health organizations, like the Alameda County Health Department and non-profit Kaiser Permanente, are moving into the communities, forming coalitions within them, and working with community leaders to create infrastructures that can sustain beneficial changes. Here at UC Berkeley, a professor was interested in establishing an anti-smoking campaign in a local neighborhood. Instead of just posting no-smoking signs around the neighborhood, she decided to consult with neighborhood residents. When she asked them what their concerns were, she found that while smoking was an issue, they were really concerned about curtailing speeding down their residential streets.

As a result of this conversation, researchers at the university worked with these people to create the infrastructure necessary to work towards their needs. The neighborhood group worked for a year and managed to get the city to install the speed bumps. All the while, this professor slowly moved out of the picture, giving them the mandate to determine their own path. A year after this success, the same organization is still active, completely autonomous, and has recently taken on an anti-smoking campaign. This is a good example of how to create long-lasting change, and this is the direction that Public Health is moving.

Public Health has a long way to go. There are still massive disparities among minorities, and the issues that are most important to individuals in a community are not always addressed. But officials are trying to listen. So the next time you run into lamp-post, let your local public health official know. Maybe we will pad a pole for you too.